System and method for an integrated disease management system

ABSTRACT

An apparatus, method, and system for the design, administration and implementation of integrated disease management. The integrated disease management (“IDM”) system maximizes contact and enrollment rates of traditional remote disease management alone. This is accomplished through the creation of a system that combines telephonic-delivered disease management (i.e. traditional disease management) with work-site based health center clinician (“trusted clinician”). The IDM program is characterized by the involvement of a trusted clinician who actively participates in the disease management program by being involved in the stratification process, the contact step and the process of creating and updating the patient&#39;s individualized care plan. Therefore, the IDM program also allows the clinician to be involved in both contact and enrollment phases of the program. The IDM program further increases the efficiency of the disease management program by allowing employers to realize higher returns on their investment into such programs.

FIELD

The present invention is directed generally to disease management, andmore particularly, to a computer system and method for the design,administration, and implementation of integrated disease management.

BACKGROUND

Disease management is a coordinated healthcare delivery program with thegoal of improving overall health. As defined by the Disease ManagementAssociation of America, disease management is generally a system forcoordinating healthcare interventions and communications for peoplehaving conditions in which patient self-care efforts are significant. Adisease management program typically supports (1) the physician or otherclinician/patient relationship and plan of care, (2) emphasizesprevention of disease exacerbations and complications utilizingtreatment guidelines and patient empowerment strategies, and (3)evaluates clinical, humanistic, and economic outcomes on an on-goingbasis.

Many organizations offer disease management programs that providetelephonic contacts to patients diagnosed with a single disease, andprovide supporting education materials to those patients. Diseases thathave typically been focused on are: congestive heart failure, chronicobstructive pulmonary disease, asthma, diabetes and coronary arterydisease (CAD). In general, disease management programs have severalcomponents which would typically include: population identificationprocess; evidence-based practice guidelines; patient self-managementeducation (including primary prevention, behavior modification programs,and compliance/surveillance); process and outcome measurement,evaluation, and management; and a routine reporting/feedback loop(including communication with patient, physician/clinician, health planand ancillary providers, and practice profiling).

Traditionally implemented disease management programs have beentelephonic based systems which implement these above mentionedcomponents in successive phases. As an example, a model for implementingtelephonic-delivered disease management programs could include a phasefor identifying patients who may benefit from the program and creating atarget list of those patients, another phase for contacting patients onthe list by telephonic and other communication media, yet another phasefor enrolling the contacted patient as a participant in the program, andfinally a phase for executing patient intervention programs to achievebehavior change and subsequent improvement in outcomes. In a telephonicprogram, enrollment is based upon a case manager successfully recruitingpatients to join the program over the phone.

In the first phase, traditional disease management programs identifiedpatients on certain criteria, which included at least an analysis of thepatient's prior claims and medical history. In these programs, theselection of patients to be contacted was done by a case manager or acomputer system that would analyze certain data to determine eligibilitywithout personal knowledge of the patient from prior relationship (i.e.there was no input from the patient's physician to confirm that thepatient actually had a disease indicated by the patient's claim data ormedical history or the like).

In the second phase of a traditional disease management program, afteridentifying the patients to be contacted, a case manager would cold callidentified patients (i.e., contacts patients they do not know and haveno prior relationship with) to recruit them into the disease managementprogram. This contact made by a case manager was impersonal and notbased on a relationship that otherwise exists between a patient andhis/her trusted physician. Therefore, in traditionally implementedtelephonic programs cold calling by a case manager suffers theadditional inefficiency of not capitalizing of the relationship betweenthe physician who knows the patient and his/her medical history (i.e.the trusted clinician) and the patient to successfully recruit patientsto join the program over the phone.

In the third and fourth phases of the traditional disease managementprogram, the contacted patients who agreed to join the diseasemanagement program underwent assessment and were enrolled in theprogram. Thereafter, a nurse coach would create and administer anindividualized patient care plan. Traditionally, in these phases apatient's trusted clinician had no input or minimal input in thepreparation and updating of the individualized patient care plan.

Theoretically, in a traditional disease management program, the coldcalling in the second phase could result in the patient recognizing theneed for care and opting to enroll into the disease management programassociated with the case manager. In addition, theoretically, the lackof input from a patients trusted physician in the fourth phase may alsobe harmless in terms of the effectiveness of the care plan developed forthe patient. In practice however, traditional disease managementprograms have not been entirely successful because, (i) the correctpatients are not always identified due to discrepancies between apatient's actual condition and the diagnosis codes, (ii) only a smallpercentage of patients initially identified as potential participantsjoin the program and even fewer continue to remain in the program, and(iii) a patient may end up following a care plan that is rigid and notpersonally tailored for his/her needs thereby reducing the chances thatthe patient will continue to stay with the program. For example, apatient's claim data may show a diagnosis code for diabetes makinghim/her an ideal candidate to be contacted by the case manager. Inreality, however, the patient could simply have an incorrect codeshowing up in the report—a situation which a computerized system or acase manager not knowing the patient would not catch. As a result, thispatient would be added to the target population to be contacted forenrollment, but would not be enrolled in the program because he/she didnot have the disease suggested by the diagnosis codes. This failure tosuccessfully target the correct patients leads to contact and enrollmentinefficiencies. Similar inefficiencies result from the failure torecruit a diseased patient when the patient fails to enroll becausehe/she is contacted by a stranger who is not his usual or trustedclinician. Other inefficiencies also result from the failure to includethe trusted clinician's knowledge of a patient's medical history toprepare a care plan for the enrolled patient.

These inefficiencies and failures are evidenced in traditional diseasemanagement programs. Although there is some variation in the efficiencylevels at each of the four phases of a traditional disease managementprogram on a vendor and program basis, an industry estimate is a 50%success rate at each phase. Starting with 100% at the beginning of phase1; 50% of the target patient population is successfully contacted by thecompletion of phase 2; at the end of phase 3, 50% of contacted patientsagree to become program participants by enrolling (also called opt-in);and at the end of phase 4, 50% of enrolled participants exhibitmeasurable behavior change, which ultimately drives improvement indisease outcomes. Thus, the cumulative efficiency, or engagement rate,at the completion of the target patient identification, contact(outreach), and enrollment phases is 25%, or, one out of four patientson the target list enroll in the program. At the final phase this modelwould expect only 12.5% of the originally targeted patients to actuallyexhibit behavior change.

Therefore, there is a need for a disease management program thatovercomes the inefficiencies of the traditional disease managementprogram and improves the measurable outcomes of a target population byimproving the effectiveness of the intervention. There is a further needfor a disease management program that leverages the relationship betweenthe patient and a trusted physician/clinician to improve theeffectiveness of a disease management program.

SUMMARY

It is an object of the present invention to provide an integrateddisease management program that incorporates active participation of apatient's trusted clinician in (i) identifying patients who may benefitfrom the program by reviewing a patient's claim data for eligibility,(ii) contacting patients on the list in person, by telephonic or othercommunication media to explain the benefits of participating in adisease management program, and (iii) executing patient interventionprograms to reduce the chances that the patient will opt-out of theprogram, thereby improving the efficiency of the traditional diseasemanagement program.

It is yet another object of the present invention to provide anintegrated disease management program that creates a higher quality listof target patients by combining the use of a predictive modelingalgorithm with the review of identified target patients' claim data andmedical history by the patient's trusted clinician, to create the finaltarget population.

It is still another object of the present invention to provide anintegrated disease management program which incorporates the patient'strusted clinician in the contact phase to improve patient enrollmentrates.

These and other objects of the invention may be accomplished by anyknown means, including by individuals, one or more computer systems,communication systems, such as, phones, email or the like, or anycombination thereof.

BRIEF DESCRIPTION OF THE DRAWINGS

Additional aspects, features, and advantages of the invention, both asto its structure and operation, will be understood and will become morereadily apparent when the invention is considered in light of thefollowing description made in conjunction with the accompanying drawingsthat illustrate certain non-limiting embodiments of the disclosure,wherein:

FIG. 1 is a flow chart of an integrated disease management programaccording to one embodiment of the invention.

FIG. 2 is one exemplary embodiment of the integrated disease managementprogram's pharmacy referral process.

FIG. 3 is one exemplary embodiment of an integrated disease managementprogram controller.

FIG. 4 is one exemplary embodiment of an individualized care plan.

FIG. 5 is a flow chart of an integrated disease management programdepicting pre-enrollment and enrollment according to one exemplaryembodiment of the invention.

FIG. 6 is a flow chart of an integrated disease management systemdepicting re-enrollment according to one exemplary embodiment of theinvention.

DETAILED DESCRIPTION

The exemplary embodiments are discussed below with reference to on-sitehealth clinics of a large, self-insured employer's active and retireepopulation along with their adult dependents. In the exemplaryembodiments, the employer locations have an on-site primary care healthclinic and a full-service pharmacy available to active and retiredemployees and their dependents. This exemplary embodiment is presentedfor convenience only and is not intended to limit the application of thepresent invention. After reading the following description, it will beunderstood by those skilled in the art how to implement the presentinvention in alternative embodiments involving patient care.

First Exemplary Embodiment

An exemplary embodiment of an integrated disease management (IDM)program is presented herein. In this example, the integrated diseasemanagement program is a flexible, network-based application that can beused to implement a disease management program through the processoutlined in FIG. 1. As implemented in this embodiment, FIG. 1 outlines amethodology that integrates disease management with a work-site basedtrusted clinician who, for example, is a primary care physician, primarycare nurse, pharmacist or a clinical staff member at the on-site healthclinic office, to form an integrated disease management program.

Identification and Contact

At step 101 of this exemplary embodiment the IDM program incorporates apredictive model to analyze a patient's medical and pharmacy claims datato identify those patients who have the highest potential for improvinghealthcare by managing certain diseases they will encounter in theirlifetime, and consequently, to identify those patients with the highestfuture avoidable healthcare costs. As currently known in the art,predictive modeling in disease management is the process of forecastinghealthcare use/expenditure, which may be based on variables such as, (1)claims data, which contain information on patient age, gender,diagnoses, prescriptions, observed utilization and treatments, (2)clinical data, such as, lab results to forecast healthcare expenditures,and (3) data related to prior utilization and compliance withprescription regimens and plan design elements for prediction purposes.Predictive modeling based on this information can be carried out by anyknown means including, for example, using commercially availablesoftware applications sold by software vendors, such as, DxCG, Inc.,Active Health Management, Inc., Symmetry and Accordant Health Services,Inc.

In this exemplary embodiment, at this step, claims data are analyzedusing a predictive model to identify patients with at least one diseasethat is covered by the IDM program, and to determine the improvementsthat can be achieved in the patient's overall health along with theamount of avoidable overall health costs for the patient. As used inthis embodiment, avoidable cost is that portion of the costs a patientis expected to incur that may be changed or avoided through some type ofdisease management intervention. This cost/health-benefit stratificationin the predictive modeling (step 101) may be done by an application thatis used to implement the IDM program discussed in FIG. 3 below.

Predictive modeling may be entity specific, and therefore, at this step,the criteria for a cost/health-benefit stratification may be based onany individual requirements for each self-insured employer implementingthe integrated disease management program. By way of example, thecost/health-benefit stratification in the modeling may involve thefollowing steps. First, the population of employees, retirees anddependents age 18 and older who are eligible for health benefits areidentified. Next, for the patients within the identified eligiblepopulation, primary diagnosis codes from their individual medical claims(based upon International Statistical Classification of Diseases andRelated Health Problems) are used to identify patients with recordeddiagnosis codes, such as the diagnosis codes for diabetes, coronaryartery disease or essential hypertension, that are covered under adisease management program. Data for this group of eligible patients,with a condition covered by a disease management program, is included inthe predictive model which determines the avoidable costs for eachidentified patient and the corresponding predicted future healthbenefits for each patient. By way of example, the predictive model willforecast individual patient's total and avoidable healthcare costs for aforward-looking twelve (12) month period. By prioritizing patienttargeting and enrollment processes based on members with high avoidablehealthcare costs, the enrolled population will be enriched with patientswho have actionable conditions (improved efficiency) amenable to thebenefits of integrated disease management. By applying integrateddisease management programs to this enriched population, programeffectiveness is increased as measured by improved outcomes. Thiscost/health-benefit stratification in these embodiments may be done byan application that is used to implement the IDM program, which isdiscussed in FIG. 3 below.

In an alternative embodiment, each patient's proximity to the on-sitehealth clinic may also be used as an additional factor in identifyingpatients. For example, patient's whose residence is within apredetermined proximity radius, for example, a 35 mile radius, of theon-site health clinic may be considered to be geographically proximateand have access to the on-site health clinic for the medical care oftheir chronic condition. Such patients may further be classified eitheras ‘health center users’ (101 a), for example, those patients who haveused the on-site health clinic for an office visit, or as ‘proximatenon-users’ (101 b), for example, those patients who do not use theon-site health clinic for office visits. In another embodiment,proximate non-users may also include those patients who only use theon-site health clinic for acute care treatment rather than primaryhandling of their chronic condition. Patients living outside of thepredetermined proximity radius may be classified as ‘non proximate’ (101c). The resulting patient population is then stratified onhealth-benefits and avoidable costs, and those with the potential forthe most significant health improvement and, consequently, highavoidable costs are selected.

The result of step 101 is the identification of the base targetpopulation. The base target population is processed in step 102 andundergoes claim stratification. During this step, by way of example, atrusted clinician may access the base target population information viaa user interface to the application that is used to implement the IDMprogram (step 102 a). Clinician encounter data is accessed by thetrusted clinician. In this exemplary embodiment, clinician encounterdata will include, for example, administrative claim equivalent data,patient medical record information, administrative claims and healthinsurance eligibility data, or the like for the patients in the basetarget population. The trusted clinician in conjunction with the IDMcontroller (301) that is used to implement the IDM program can combineclinician encounter data with patient medical record information,administrative claims and health insurance eligibility data and identifyappropriate patients within the base target population that should beenrolled in the employer's health center's disease management program.In an alternative embodiment, the IDM controller (301) processesclinician encounter data with patient medical record information,administrative claims and health insurance eligibility data and identifyappropriate patients within the base target population that should beenrolled in the employer's health center's disease management program.

Steps 101 and 102, i.e. the stratification process, results in theselection of those patients with appropriate disease diagnoses forinclusion in a disease management program and the potential for the mostsignificant improvement in health and reduction in healthcare costs. Thereview of the target population by the trusted clinician in step 102refines the process of selecting appropriate candidates for inclusion inthe disease management program. This is the final target population(103) (i.e., the group comprising the patients from the base targetpopulation who will benefit the most from participating in a diseasemanagement program).

In this exemplary embodiment, step 102 is an improvement overtraditional methods because the trusted clinician (e.g., an entity thathas a personal relationship with the patient and is treating thepatient) can be used in identifying the target population, which inturn, allows the IDM program to improve the contact information data andclinical data of the base target population.

In step 103, the final target population list is generated. This listmay be generated, for example, at a central facility which, in thisembodiment is a network-based application that is used to implement theIDM program (FIG. 3). In this exemplary embodiment, the trustedclinician receives the patient list that is generated by the IDMcontroller (301) and saved on the IDM database (319). In otherembodiments, this list may be generated using an automated tool similarto the IDM controller or manually, and the list may be sent to, andreceived by the trusted clinician using traditional fax or emailservices or the like.

Step 104 leverages the patient's relationship with a trusted primarycare clinician or other on-site health clinic based trusted cliniciansto contact and pre-enroll patients in a disease management program fromthe final target population. Using the trusted clinician to approach apatient about enrollment in the disease management program increasesprogram effectiveness because, unlike traditional disease managementsystems, the IDM program seeks to engage both the patient and theirtrusted clinician to work together within the disease managementframework. In step 104, the initial contact with the patient may beaccomplished in several ways, for example, by telephonic, face-to-face,e-mail, web inquiry, etc. In one exemplary embodiment illustrated inFIG. 1, the trusted clinician initiates contact with the patient in atleast one of the following ways: (i) the trusted clinician discusses thedisease management program during the patient's regularly scheduledvisit to the office (step 104 a); (ii) the trusted clinician discussesthe disease management program with the patient outside of an officevisit, which by way of example, could be a telephone contact by thetrusted clinician to the patient's home (step 104 b); or (iii) thetrusted clinician discusses the disease management program with thepatient during his/her visit to the pharmacy to pick up prescribedmedication (step 104 c).

Thus as described above, the overall enrollment design in this exemplaryembodiment is “opt-in;” i.e., once the final target population isidentified, the patient is asked to consent to participate in thedisease management program after an explanation of the program services,and they may “opt-out” or refuse to continue participation at any time.

Pre-Enrollment

As a result of step 104, once a patient in the final target populationhas been contacted, the trusted clinician attempts to pre-enroll thepatient into a disease management program by educating the patient aboutthe program and the potential health/cost benefit to the patient. Aspart of the pre-enrollment, the patient agrees to be contacted by a casemanager. The patient's willingness to be contacted by a case manager ofthe disease management program (step 105) is captured in the patient'srecords, for example, in the IDM database (319) using the IDM controller(301), and is a successful pre-enrollment of the patient. In thisexemplary embodiment, a case manager is the individual responsible forinitially enrolling the patient, completing a general assessment, andscheduling a follow-up appointment with a nurse coach, who, for example,is a registered nurse providing care support and functions as a diseasemanagement nurse for patients.

The improved efficiency, in this phase of the IDM program, using thepresent method can be determined from the following equation:

${{Patient}\mspace{14mu}{contact}\mspace{14mu}{rate}} = \frac{\#\mspace{14mu}{{patient}'}s\mspace{14mu}{successfully}\mspace{14mu}{contacted}}{\#\mspace{14mu}{patients}\mspace{14mu}{in}\mspace{14mu}{final}\mspace{14mu}{target}\mspace{14mu}{population}}$

In this exemplary embodiment, successfully pre-enrolled patients are, byway of example, made accessible to a case manager while the patient isat the on-site health clinic or during a telephone conversation. If thepatient does not have time while on-site to complete a generalassessment (wellness and lifestyle assessment) with the case manager,the trusted clinician obtains a best day and time for contacting thepatient, completes a referral/communication form, and faxes allinformation to the case manager. As a result of this step (105), anadjusted target population of patients is identified comprising the setof patients from the final target population who have been contacted bythe trusted clinician and have consented to pre-enrollment. This groupcomprises a set of selected patients who will benefit from participatingin a disease management program and have consented to complete theenrollment process in the disease management program. In an alternativeembodiment, information about (1) the patient's general assessment withthe case manager, (2) the best day and time for the nurse coach tocontact the patient for a follow-up appointment, or (3) information on areferral/communication form is saved in the IDM database (319) using theIDM controller (301). It is to be noted that in a situation wherein allpatients in the final target population agree to pre-enrollment, thegroup comprising the adjusted target population (i.e. patients who haveagreed to be contacted by a case manager) is identical to the finaltarget population.

Enrollment

In step 106, a case manager associated with the entity administering thedisease management program contacts the patient and completes enrollmentof the patient in the disease management program. By way of example, theenrollment process may include filling-out a questionnaire, a generalassessment, providing educational material regarding the disease to bemanaged, and/or the like. As another example, the process of patientenrollment may be conducted on-line, via access to the IDM controller301, where the enrollee would access the necessary forms to befilled-out and would also have access to educational and other materialrelated to the disease and the disease management program. If, forexample, the patient is contacted by the trusted clinician duringhis/her visit to the on-site health clinic (step 104 a), then during thevisit itself, a case manager may make the initial call to the patientwhile he/she is at the on-site health clinic, complete the generalassessment and schedule a follow-up appointment with a nurse coach. Thissecond contact step of enrolling the patient into the disease managementprogram results in increased enrollment efficiency which is, forexample, evident in the higher enrollment rate for patients exposed tothe IDM program than for patients exposed to the traditional diseasemanagement program. At least one factor attributable to this increasedenrollment efficiency is the unique approach of steps 101 and 102 ofthis exemplary embodiment of the IDM program and the correspondingsuccess of the pre-enrollment step 102. The patient enrollment ratemetric may be defined as:

${{Patient}\mspace{14mu}{enrollment}\mspace{14mu}{rate}} = \frac{\#\mspace{14mu}{{patient}'}s\mspace{14mu}{enrolled}}{\#\mspace{14mu}{patients}\mspace{14mu}{successfully}\mspace{14mu}{contacted}\mspace{11mu}\left( {{adjusted}\mspace{14mu}{target}\mspace{14mu}{population}} \right)}$

Once enrolled, in step 107, the patient receives an individualized careplan (FIG. 4), which represents an outline i.e. a blue-print of the IDMprogram for a particular patient. In this exemplary embodiment, thepatient enrolled in the IDM program receives a care plan that tracks thepatient's progress during their participation in the program. Officevisit data and test results are recorded along with detail notes made bythe nurse coach. This information may be gathered and updated, forexample, by the IDM controller 301. In this exemplary embodiment, anurse coach, who, for example, is a registered nurse, provides caresupport and functions as a disease management nurse for patients of theadjusted target population. A case manager is responsible for initiallyenrolling the patient, completing a general assessment, and schedulingthe nurse coach follow-up appointment.

Step 108 is unique to the IDM program because once again, the patient'srelationship with the trusted clinician again leveraged to modify thepatient's individualized care plan to suit the patient. In this step,the three main entities of the IDM program, for example, the trustedclinician, the patient and the nurse coach discuss the issues, problems,required level of care, etc. and decide on a care plan that all entitiesare comfortable with and a plan that has a high rate of success. It isto be noted that this step may be different from a traditional diseasemanagement program wherein, for example, a nurse coach would makedecisions with or without input from the trusted clinician. In thisembodiment, however, the IDM program includes the trusted clinician inthe decision making process to increase program effectiveness.

After step 108, the IDM program performance metrics are determined (step109) to evaluate the effectiveness of the IDM program. By way ofexample, such performance metrics would involve the use of three metricsto evaluate enrollment effectiveness: (i) contact rate, i.e. the numberof individuals successfully contacted divided by the number ofindividuals in the final target population, where a successful contactis talking with an individual, (ii) enrollment rate, i.e. the number ofindividuals enrolled into the program divided by the number ofindividuals successfully contacted (adjusted target population) whereenrollment is securing an individuals agreement to participate in theprogram and completing an initial 15-20 minute assessment, and (iii)engagement rate, i.e. the weighted enrollment rate which is the productof the contact rate multiplied by the enrollment rate.

In alternative embodiments, additional metrics dealing with healthoutcomes and participant satisfaction can be combined with theenrollment effectiveness measures to evaluate the overall programeffectiveness.

Second Exemplary Embodiment

A second exemplary embodiment of an integrated disease managementprogram is presented herein. In this example, the integrated diseasemanagement program is a flexible, network-based application that can beused to implement a disease management program through a pharmacyreferral process outlined in FIG. 2.

In this embodiment, at step 201, the patient attempts to get aprescription filled. The pharmacist (i.e. trusted clinician) checks thepatient medication to see if he/she is being treated for any diseasethat is covered by the health center disease management program. If yes,then at step 202, the pharmacist accesses the patient information, forexample, from the application used to implement the IDM program (FIG.3). If a query to the IDM controller (301) determines that the patientis an on-site health clinic user, then no action is taken and thepatient will be contacted/enrolled as described in the exemplaryembodiment of FIG. 1 (step 203). If the patient is not an on-site healthclinic user, then at step 204, the pharmacist discusses the diseasemanagement program with the patient and can, for example, giveinformative material regarding the disease and the program to thepatient. Next, at step 205, the pharmacist updates the patientsinformation in the IDM controller (301) and can also fax the referral toa case manager. At step 206, a case manager at the entity administeringthe disease management program generates a list of all patients withupdated pharmacy records by, for example, accessing the IDM controller(301). In an alternative embodiment a case manager can also use a listthat is faxed by the pharmacy to initiate the contact with the patients.At step 207, a case manager makes the outbound call attempt, and asdetailed in the exemplary embodiment of FIG. 1, continues to performsteps similar to step 106-step 109.

Third Exemplary Embodiment

A third exemplary embodiment of an integrated disease management programis presented herein. In this example, the integrated disease managementprogram is a flexible, network-based application that can be used toimplement a disease management program through a pre-enrollment andenrollment process outlined in FIG. 5.

In this embodiment, after step 104 (FIG. 1), at step 501 the patient isintroduced to the disease management program. If the patient agrees, heor she is pre-enrolled and the patient's record is updated in the IDMdatabase (319) using the IDM controller (301). Alternatively, if thepatient declines, the patient record is updated in the IDM database(319) using the IDM controller (301) (step 502). In this exemplaryembodiment, the trusted clinician completes an on-line referral form byaccessing the form via a remote connection to the IDM controller (301)(step 503). This referral form may be alternatively generated as a fax,email, secure message, phone call or other standard communicationmethod. At step 504, in this exemplary embodiment, the control passes toa case manager, who accesses the IDM controller (301) to generate a listof patients that have pre-enrolled in the disease management program(i.e. the group of second selected patients). After accessing patientinformation, the case manager contacts the patients in this group. Inthis exemplary embodiment, the contact by a case manager may be, forexample, an outbound contact call from the case manager to the patientwithin 1 business day of generating the list (step 505). If contact ismade, and the patient agrees to the enrollment, the case managercompletes a general assessment (step 506) and schedules an appointmentwith a nurse coach (step 507). If the patient declines, the on-sitehealth clinic is notified and the patient record is updated (step 510)in the IDM controller (301). Once follow-up appointment with the nursecoach is complete and the patient is enrolled in the disease managementprogram, the nurse coach updates the IDM database (319) using the IDMcontroller (301) for the patient. In this exemplary embodiment, in theevent that no contact is made with the patient the nurse coachreschedules a general assessment to be completed the following week(step 508). In this regard, the nurse coach makes two attempts over thesubsequent two weeks to contact the patient. If no contact is made, thenurse coach updates the IDM controller (301) and sends a no-contactpostcard to the patient (step 509). If there is still no response, or ifthe patient declines, the nurse coach notifies the on-site health clinicof the same and updates the IDM database (319) using the IDM controller(301) for the patient (step 510). This notification to the on-sitehealth clinic may be in the form of a report generated by the IDMcontroller (301), or alternatively, this notification may be in the formof a fax, email, secure message, phone call or other standardcommunication method.

Fourth Exemplary Embodiment

A fourth exemplary embodiment of an integrated disease managementprogram is presented herein. In this example, the integrated diseasemanagement program is a flexible, network-based application that can beused to implement a disease management program through a re-enrollmentprocess outlined in FIG. 6.

In this embodiment, for re-enrollment of a patient after non-enrollmentverification of eligibility of the patient must be completed, which isconducted by a trusted clinician or a nurse coach in conjunction withthe IDM controller (301), as discussed in FIG. 1. At step 601 a-c, alist containing a population of patients who are eligible forre-enrollment is generated. By way of example, this list can begenerated by any one or more of the following: (i) a nurse coachgenerates a list of re-enrollees, (ii) an on-site health clinic staffmember contacts a nurse coach with a list of re-enrollees, or (iii) apatient calls in requesting enrollment in the disease managementprogram. In this embodiment, only a nurse coach may re-enroll a memberinto the IDM program to ensure appropriate clinical assessment, forexample, by making the outbound call to the patient. Steps 602 a-c and603 a-c are conducted by the nurse coach. Next, at step 610 the nursecoach will need to obtain verification of eligibility of the patient by,for example, accessing the patient's records in the IDM database (319)using the IDM controller (301). In alternative embodiments, verificationof eligibility can be done by contacting the on-site health clinic.

In steps 602 a-c the nurse coach determines when the last contact wasmade. If 90 or more days have elapsed since last patient contact, thenthe nurse coach must complete general and disease specific assessment(step 603 a) and, by way of example, the patient's answers are used bythe IDM controller (301) to creates a customized care plan includingsuggested educational material, clinical outreach/referral, follow-upfrequency etc. In alternative embodiments, these assessments areconducted annually and on an “adhoc” basis if there is a dramatic changein health status. If 60 days have elapsed since last patient contact,then the nurse coach must complete only the disease specific assessment(step 603 b). If 30 days or less have elapsed since last patientcontact, then the nurse coach must complete a disease specific follow-upassessment (step 603 c). By way of example, a disease-specific follow-upassessment is a shortened version of the disease-specific assessment andis used as a guide by the nurse coach during monthly follow-up contacts.In this exemplary embodiment, such an assessment is a manual process andentered as a narrative note in the IDM controller (301), is notmandatory, but is used as a guide for the nurse coach to structure theinteraction, if desired. At step 604, the IDM program determines ifassessment is complete. If yes, and if the patient is a current on-sitehealth clinic user, then the patient's record is updated (step 608) andthe patient is re-enrolled (step 605). If assessment is complete and thepatient is not a current on-site health clinic user, then the patient'srecord is created and, in this exemplary embodiment, the on-site healthclinic is notified of the patient's desire to start using the healthcenter (step 606). The trusted clinician then schedules an appointmentwith the patient and the patient is re-enrolled (step 607).

Integrated Disease Management Controller

FIG. 3 is of a block diagram illustrating one exemplary embodiment ofaspects of an integrated disease management (IDM) controller 301 whichcan be used to implement the foregoing processes. In this exemplaryembodiment, the IDM controller 301 in FIG. 3 is based on common computersystems that may comprise, but is not limited to, components such as acomputer systemization 302 connected to memory 323.

A computer systemization 302 may comprise a clock 330, centralprocessing unit (CPU) 303 which comprises at least one high-speed dataprocessor adequate to execute program modules for executing user and/orsystem-generated requests, a read only memory (ROM) 306, a random accessmemory (RAM) 305, and/or an interface bus 307, and most frequently,although not necessarily, are all interconnected and/or communicatingthrough a system bus 304. Optionally, the computer systemization may beconnected to an internal power source 386 and any of the abovecomponents may be connected directly to one another, connected to theCPU, and/or organized in numerous variations employed as exemplified byvarious computer systems.

Generally, any mechanization and/or embodiment allowing a processor toaffect the storage and/or retrieval of information is regarded as memory323. It is to be understood that the IDM controller 301 and/or acomputer systemization 302 may employ various forms of memory 323. In atypical configuration, memory 323 will include ROM 306, RAM 305, and astorage device 314. The memory 323 may also contain a collection ofprogram and/or database modules and/or data such as, but not limited to:operating system module(s) 315, information server module(s) 316, userinterface module(s) 317, Web browser module(s) 318, database(s) 319, IDMmodule(s) 335, and/or the like. These modules may be stored and accessedfrom the storage devices and/or from storage devices accessible throughan interface bus. Although non-conventional software modules such asthose in the module collection, typically, are stored in a local storagedevice 314, they may also be loaded and/or stored in memory such as:peripheral devices, RAM, remote storage facilities through acommunications network, ROM, various forms of memory, and/or the like.

In this embodiment, the IDM controller 301 may be connected to and/orcommunicate with entities such as, but not limited to: one or more usersfrom user input devices 311, peripheral devices 312, and/or acommunications network 313. It should be noted that although user inputdevices and peripheral devices may be employed, the IDM controller maybe embodied as an embedded, dedicated, and/or monitor-less (i.e.,headless) device, wherein access would be provided over a networkinterface connection.

The IDM controller 301 serves to process, store, search, serve,identify, instruct, generate, match, and/or update information,expirations, and/or other related data, such as, for example, accessingthe IDM database 319 via the IDM module(s) 335 of the memory 323 toretrieve patient information, transmitting the patient information tothe case manager or on-site health clinic, updating patient information,storing individualized care plans. Typically, users, which may bepeople, for example, clinicians, nurse coach, health servicerepresentative, case manager, and/or other systems, engage informationtechnology systems (e.g., commonly computers) to facilitate informationprocessing.

An IDM database 319 may be embodied in a database and its stored data.The database may include stored program code, which is executed by theCPU; the stored program code portion configuring the CPU to process thestored data. In this embodiment, the IDM database 319 includes severaltables, for example, 319 a-c. A patients table 319 a may include fieldssuch as, but not limited to: a patient's name, address, patient_id;claim_id; diagnosis_id, contact_id, enrollment_id and/or the like. Thepatients table may support and/or track multiple entity accounts on athe IDM program. A clinician encounter data table 319 b includes fieldssuch as, but not limited to: encounter_id, admin_user_id (a user givenadministrative status to control the account), patient_id, and/or thelike. For example, a patient's visit to his/her primary care specialistmay have its unique encounter_id key field used as part of the patient'stable as one way to track encounters per patient. An administrativeclaims data table 319 c includes fields such as, but not limited to:claim_id; patient_id, encounter_id, diagnosis_code and/or the like. Forexample, a patient's visit to his/her primary care specialist may haveits unique claim_id key field used as part of the patient's table as oneway to track claims per patient.

The IDM database 319 may communicate to and/or with other modules in amodule collection, including itself, and/or facilities of the like. Mostfrequently, the IDM database 319 communicates with an IDM module 335,other program modules, and/or the like. The database may contain,retain, and provide information regarding other nodes and data, and mayalso be replicated at time intervals.

IDM module(s) 335 is stored program code that is executed by the CPU.The IDM module affects accessing, obtaining and the provision ofinformation, services, transactions, and/or the like across variouscommunications networks. The IDM module 335 enables the selection of thetarget population for a disease management program and customization ofthe manner in which information about the program participants, such aspatients, clinician, case manager etc., can be captured, processed anddisplayed via a web client interface. In this embodiment, the IDMcontroller 301 employs the web server and user interface modules toobtain user inputs to, for example, specify selection criteria forpotential patients based on target population and clinician encounterdata, patient information, administrative claims and health insuranceeligibility data and generates, for example, final target populationlist. By way of example, one non-limiting exemplary embodiment for thedeployment of an integrated disease management program is implemented asan application in accordance with an Internet protocol, such as theHTTP, Extensible Markup Language (“XML”), or HTML protocol.

The configuration of the IDM controller 301 will depend on the contextof system deployment. Factors such as, but not limited to, the budget,capacity, location, and/or use of the underlying hardware resources mayaffect deployment requirements and configuration. Regardless of if theconfiguration results in more consolidated and/or integrated programmodules, results in a more distributed series of program modules, and/orresults in some combination between a consolidated and distributedconfiguration, data may be communicated, obtained, and/or provided.

Overview of the System Process

An exemplary embodiment of an integrated disease management (IDM) systemprocess is presented herein. The IDM controller 301 manages the patientinformation and the predictive modeling algorithm for selecting patientsbased on cost/health-benefit and claim stratification. The IDMcontroller 301 receives a request to generate a list of eligiblepatients i.e. final target population, and transmits the list to theuser i.e. trusted clinician. The trusted clinician accesses the list viaa user interface on a remote terminal that is connected to a centralfacility i.e. the IDM controller 301. The trusted clinician can use theIDM controller 301 to generate the contact with a patient if, forexample, the contact is made via e-mail or the like. Alternatively, asdiscussed hereinabove, the trusted clinician can contact the patient viaa telephone. Once contacted, the patient's response to the contact isupdated in the IDM controller 301. In this embodiment, for example,patient information is updated by using a user interface on a remoteterminal that is connected to the IDM controller 301, and once saved,the IDM database 319 record for the patient is updated. As a result ofthese processes, the IDM controller 301 is able to identify thosepatients who are eligible for participating in a disease managementprogram and have consented to participate in such a program after beingcontacted by a trusted clinician who has, at least, explained theprogram and its benefits to the patient.

Thereafter, the IDM controller 301 receives another request to generatea list of contacted patients i.e. the pre-enrolled patients andtransmits the list to the user i.e. case manager. The case manageraccesses the list via a user interface on a remote terminal that isconnected to a central facility i.e. the IDM controller 301. The casemanager can use the IDM controller 301 to generate the contact with apatient if, for example, the contact is made via e-mail or the like.Alternatively, as discussed hereinabove, the case manager can contactthe patient via a telephone to complete a general assessment and enrollthe patient in a particular intervention program. Once this contact issuccessfully made, the patient's response to the contact is updated inthe IDM controller 301. In this embodiment, for example, patientinformation is updated by using a user interface on a remote terminalthat is connected to the IDM controller 301, and once saved, the IDMdatabase 319 record for the patient is updated. As a result of theseprocesses, the IDM controller 301 is able to identify those patientswho, since pre-enrolling, have enrolled in a program after beingcontacted by a case manager who has, at least, completed a generalassessment of the patient and has scheduled a follow-up visit with anurse coach. Once enrollment is complete, the nurse coach with inputfrom the patient and clinician accesses the IDM controller 301 todevelop an individualized care plan for a patient, which is saved in theIDM database 319.

The center of the process revolves around the storage and management ofpatient information, claim data, contact information and care planinformation in the IDM database 319. During the various processesdescribed above, patient and other data related to the patient andhis/her care is retrieved and/or updated in the IDM database 319 asrequired.

The entirety of this disclosure shows by way of illustration variousembodiments in which the claimed invention may be practiced. Indescribing embodiments of the invention, in some cases specificterminology has been used for the sake of clarity, however, theinvention is not intended to be limited to and/or by the specific termsso selected, and it is to be understood that each specific term includesall technical equivalents which operate in a similar manner toaccomplish a similar purpose. It should be noted that terms and orphraseology in this disclosure are not exhaustive in detail, and are notprovided as definitive definitions. Rather, the terms are providedherein simply as an aid to the reader. The terms are not limiting of thedisclosure and/or claims herein. The use of the terms may contemplateany of the broader, and/or multiple meanings found in common use,dictionaries, technical dictionaries, and/or in actual use in thetechnical arts, as well as any broadening made throughout thisdisclosure.

Also, the advantages and features of the disclosure are of arepresentative sample of embodiments only, and are not exhaustive and/orexclusive. They are presented only to assist in understanding and teachthe claimed principles. It should be understood that they are notrepresentative of all claimed inventions. As such, certain aspects ofthe disclosure have not been discussed herein. That alternateembodiments may not have been presented for a specific portion of theinvention or that further undescribed alternate embodiments may beavailable for a portion is not to be considered a disclaimer of thosealternate embodiments. It will be appreciated that many of thoseundescribed embodiments incorporate the same principles of the inventionand others are equivalent. Thus, it is to be understood that otherembodiments may be utilized and functional, logical, organizational,sequence, structural, temporal, and/or topological modifications may bemade without departing from the scope and/or spirit of the disclosure.As such, all examples and/or embodiments are deemed to be non-limitingthroughout this disclosure.

Also, no inference should be drawn regarding those embodiments discussedherein relative to those not discussed herein other than it is as suchfor purposes of space and reducing repetition. For instance, it is to beunderstood that the logical and/or topological structure of anycombination of any program components (a component collection), othercomponents and/or any present feature sets as described in the figuresand/or throughout are not limited to a fixed operating order and/orarrangement, but rather, any disclosed order is exemplary and allequivalents, regardless of order, are contemplated by the disclosure.Furthermore, it is to be understood that such features are not limitedto serial execution, but rather, any number of threads, processes,services, servers, and/or the like that may execute asynchronously,concurrently, in parallel, simultaneously, synchronously, and/or thelike are contemplated by the disclosure. As such, some of these featuresmay be mutually contradictory, in that they cannot be simultaneouslypresent in a single embodiment. Similarly, some features are applicableto one aspect of the invention, and inapplicable to others. In addition,the disclosure includes other inventions not presently claimed. As such,it should be understood that aspects of the disclosure such asadvantages, embodiments, examples, features, functional, logical,organizational, sequence, structural, temporal, topological, and/orother aspects are not to be considered limitations on the disclosure asdefined by the claims or limitations on equivalents to the claims.

What is claimed is:
 1. A method for coordinated healthcare delivery foruse with a controller, said controller including a processor and amemory communicatively coupled to said processor and having instructionsthat are executable by said processor, said method comprising:generating a base target population of patients by analyzing, using saidprocessor, claim data of each of a plurality of patients to determine asubset of said plurality of patients who are expected to realize ahigher benefit from enrolling in a coordinated healthcare deliveryprogram than other patients of said plurality of patients, wherein saidbase target population of patients is said subset of said plurality ofpatients; generating, by said processor, a list of one or more patientsin said base target population of patients that have had a previouscontact with a clinician; providing, using said processor, said claimdata of each patient in said list of one or more patients in said basetarget population of patients to said clinician; receiving, using saidprocessor, for each patient of said base target population of patientsin said list of one or more patients, an indication from said clinicianwith whom said patient has had said previous contact as to whether saidpatient is an appropriate candidate for enrollment in said coordinatedhealthcare delivery program, wherein said clinician with whom saidpatient has had said previous contact provides said indication based ona review of said claim data of said patient; generating, using saidprocessor, a final target population of patients, wherein said finaltarget population of patients is a subset of said base target populationof patients, wherein each patient of said final target population ofpatients has been indicated, by said clinician with whom said patienthas had said previous contact, to be an appropriate candidate forenrollment in said coordinated healthcare delivery program based on saidreview of said claim data of said patient; contacting patients from saidfinal target population of patients, wherein, for each patient, saidcontact is made by said clinician with whom said patient has had saidprevious contact; providing an identification of an adjusted targetpopulation of patients to a case manager responsible for enrollingpatients from said adjusted target population of patients in saidcoordinated healthcare delivery program, wherein said adjusted targetpopulation comprises each patient from said final target population ofpatients who has agreed, during said contact by said clinician with whomsaid patient has had said previous contact, to be contacted by said casemanager for enrollment in said coordinated healthcare delivery programafter said contact by said clinician; contacting said patients from saidadjusted target population of patients for enrollment in saidcoordinated healthcare delivery program, wherein, for each patient, saidcontact is made by said case manager after receiving said identificationof said adjusted target population of patients; enrolling at least onepatient from said adjusted target population of patients in saidcoordinated healthcare delivery program, wherein said enrolling isperformed by said case manager after receiving said identification ofsaid adjusted target population of patients; and generating a care planfor each enrolled patient, wherein said care plan is developed basedupon interaction between one or more of said enrolled patient, saidclinician with whom said enrolled patient has had said previous contact,and a nurse coach.
 2. The method of claim 1, wherein said clinician ispart of an on-site health clinic or pharmacy.
 3. The method of claim 1,further comprising transmitting a list of said final target populationof patients by at least one of: (i) a central facility to a remoteterminal within a peer-to-peer network or any data communication networkcapable of transmitting and receiving data from said central facility tosaid remote terminal; or (ii) an email, fax, secure message, phone callor other standard communication method.
 4. The method of claim 1,wherein providing said identification of said adjusted target populationof patients to said case manager comprises providing said identificationby at least one of: (i) a central facility to a remote terminal within apeer-to-peer network or any data communication network capable oftransmitting and receiving data from said central facility to saidremote terminal; or (ii) an email, fax, secure message, phone call orother standard communication method.
 5. The method of claim 1, whereinsaid case manager is at least one of a registered nurse, a healthservice representative or a coordinated healthcare deliveryrepresentative.
 6. The method of claim 1, wherein each patient from saidfinal target population of patients is contacted by at least one of: (i)said clinician during said patient's visit to an on-site pharmacy topick up prescribed medication; or (ii) said clinician outside of saidpatient's visit to an on-site health clinic and via any one of an email,a fax, a secure message, a phone call or other standard communicationmethod.
 7. The method of claim 1, wherein said clinician is any one of aprimary care physician, a registered nurse, a nurse's assistant, apharmacist, a pharmacy assistant or any other work-site based clinicianwith whom said patient has a preexisting medical relationship.
 8. Themethod of claim 1, further comprising rendering individualized patientcare to each of said enrolled patients from a list of said adjustedtarget population of patients in accordance with said generated careplan.
 9. The method of claim 1, wherein patient information for each ofa list of said final target population of patients and a list of saidadjusted target population of patients is stored in a central facilitythat can be accessed from a remote terminal connected to said centralfacility via a network.
 10. A method for coordinated healthcare deliveryfor use with a controller, said controller including a processor and amemory communicatively coupled to said processor and having instructionsthat are executable by said processor, said method comprising:receiving, from said processor, an identification of a base targetpopulation of patients generated by said processor by using a predictivemodel on a population of patients who are eligible to enroll in acoordinated healthcare delivery program to determine, for each of saideligible patients: (i) an amount of health costs said patient isexpected to incur that may be avoided by enrollment in said coordinatedhealthcare delivery program; and (ii) a prediction of future healthbenefits corresponding to said amount of health costs that said patientmay avoid by enrolling in said coordinated healthcare delivery program,wherein said base target population of patients is a subset of saideligible population of patients who are expected to realize a higherbenefit, based on said predictive modeling of said amount of healthcosts that may be avoided and said corresponding future health benefits,than other ones of said eligible patients; receiving, from saidprocessor, a list of one or more patients in said base target populationof patients that have had a previous contact with a clinician; providingan indication to said processor, for each patient in said list of one ormore patients in said base target population of patients, as to whethersaid patient is an appropriate candidate for enrollment in saidcoordinated healthcare delivery program based on a review of claim dataof said patient by a clinician; receiving, from said processor, anidentification of a final target population of patients, wherein saidfinal target population of patients is a subset of said base targetpopulation of patients, wherein each patient of said final targetpopulation of patients is a patient who has been indicated to be anappropriate candidate for enrollment in said coordinated healthcaredelivery program based on said review of said claim data of said patientby said clinician with whom said patient has said preexisting medicalrelationship; contacting patients from said final target population ofpatients, wherein, for each patient, said contact is made by saidclinician with whom said patient has said preexisting medicalrelationship; receiving an identification of an adjusted targetpopulation of patients, wherein said adjusted target populationcomprises each patient from said final target population of patients whohas agreed, during said contact by said clinician with whom said patienthas said preexisting medical relationship, to enroll in said coordinatedhealthcare delivery program, and wherein said processor is used todetermine which patients of said final target population of patients areincluded in said adjusted target population of patients; and renderingindividualized patient care, to each patient enrolled in saidcoordinated healthcare delivery program, by said clinician with whomsaid enrolled patient has said preexisting medical relationship, whereineach enrolled patient is at least one of a member of said adjustedtarget population of patients transmitted to a case manager, a patientcontacted for enrollment in said coordinated healthcare delivery programby a case manager who does not have a medical relationship with saidpatient prior to contacting said patient for said enrollment in saidcoordinated healthcare delivery program, or a patient enrolled in acoordinated healthcare delivery program, and wherein an individualizedcare plan for each of said enrolled patients is developed based uponinteraction between said enrolled patient and at least one of saidclinician with whom said enrolled patient has said preexisting medicalrelationship or a nurse coach.
 11. The method of claim 10, whereinreceiving, from said processor, said identification of said final targetpopulation of patients comprises receiving said identification by atleast one of: (i) a central facility to a remote terminal within apeer-to-peer network or any data communication network capable oftransmitting and receiving data from said central facility to saidremote terminal; or (ii) an email, fax, secure message, phone call orother standard communication method.
 12. The method of claim 10, whereinreceiving said identification of said adjusted target population ofpatients comprises receiving said identification by at least one of: (i)a central facility to a remote terminal within a peer-to-peer network orany data communication network capable of transmitting and receivingdata from said central facility to said remote terminal; or (ii) anemail, fax, secure message, phone call or other standard communicationmethod.
 13. The method of claim 10, wherein each patient from said finaltarget population of patients is contacted by at least one of: (i) saidclinician during said patient's visit to an on-site pharmacy to pick upprescribed medication; or (ii) said clinician outside of said patient'svisit to an on-site health clinic and via any one of an email, a fax, asecure message, a phone call or other standard communication method. 14.The method of claim 10, wherein said clinician is any one of a primarycare physician, a registered nurse, a nurse's assistant, a pharmacist, apharmacy assistant or any other work-site based clinician.
 15. Themethod of claim 1, further comprising: generating a re-enrollmentpopulation of patients, wherein each patient in said re-enrollmentpopulation has at least one of a group of diseases requiring coordinatedhealthcare delivery, is eligible to enroll for coordinated healthcaredelivery, and is eligible for re-enrollment in said coordinatedhealthcare delivery program; transmitting a list of said re-enrollmentpopulation of patients to said nurse coach; contacting said patientsfrom said list of said re-enrollment population of patients, whereinsaid contact is made by said nurse coach; completing assessment of eachof at least one of said contacted patients; and re-enrolling at leastone of said contacted patients in said coordinated healthcare deliveryprogram.
 16. The method of claim 15 wherein each of said patientseligible for re-enrollment in said coordinated healthcare deliveryprogram is at least one of: a patient who is currently not enrolled insaid coordinated healthcare delivery program; a patient of said finaltarget population of patients who declined enrollment during saidcontact by said clinician with whom said patient has had said previouscontact; a patient of said adjusted target population of patients whodeclined enrollment during said contact by said case manager; a patientwho has contacted a health clinic or a clinician with whom said patienthad a previous contact to enroll into said coordinated healthcaredelivery program; a patient who was previously enrolled in saidcoordinated healthcare delivery program which has since expired; or apatient who is a new employee or is newly diagnosed with at least one ofsaid group of diseases.
 17. A method for coordinated healthcare deliveryfor use with a controller, said controller including a processor and amemory communicatively coupled to said processor and having instructionsthat are executable by said processor, said method comprising:identifying a population of patients who are eligible to enroll in acoordinated healthcare delivery program; generating, using saidprocessor, a base target population of patients from said eligiblepopulation of patients based on predictive modeling of at least one ofimproved health benefits or avoidable health costs, wherein said basetarget population of patients is a subset of said eligible population ofpatients; generating, using said processor, a list of one or morepatients in said base target population of patients that have had aprevious contact with a clinician; receiving, using said processor, foreach patient of said base target population of patients in said list ofone or more patients, an indication from said clinician with whom saidpatient has had a previous contact as to whether said patient is anappropriate candidate for enrollment in said coordinated healthcaredelivery program, wherein said clinician with whom said patient has hadsaid previous contact provides said indication based on a review ofclaim data of said patient; generating, using said processor, a finaltarget population of patients, wherein said final target population ofpatients is a subset of said base target population of patients, whereineach patient of said final target population of patients has beenindicated, by said clinician with whom said patient has had saidprevious contact, to be an appropriate candidate for enrollment in saidcoordinated healthcare delivery program based on said review of saidclaim data of said patient; contacting patients from said final targetpopulation of patients, wherein, for each patient, said contact is madeby said clinician with whom said patient has had said previous contact;providing an identification of an adjusted target population of patientsto a case manager responsible for enrolling patients from said adjustedtarget population of patients in said coordinated healthcare deliveryprogram, wherein said adjusted target population comprises each patientfrom said final target population of patients who has agreed, duringsaid contact by said clinician with whom said patient has had saidprevious contact, to be contacted by said case manager for enrollment insaid coordinated healthcare delivery program after said contact by saidclinician; contacting said patients from said adjusted target populationof patients for enrollment in said coordinated healthcare deliveryprogram, wherein, for each patient, said contact is made by said casemanager after receiving said identification of said adjusted targetpopulation of patients; enrolling at least one patient from saidadjusted target population of patients in said coordinated healthcaredelivery program, wherein said enrolling is performed by said casemanager after receiving said identification of said adjusted targetpopulation of patients; and generating a care plan for each enrolledpatient.
 18. The method of claim 1, wherein said plurality of patientscomprises an eligible population of patients selected from a group ofpatients having at least one of a group of diseases requiringcoordinated healthcare delivery, wherein each eligible populationpatient is eligible to enroll for coordinated healthcare delivery, andwherein generating said base target population of patients is performedbased on predictive modeling of at least one of improved health benefitsor avoidable health costs.
 19. The method of claim 10, wherein saideligible population of patients comprises patients selected from a groupof patients having at least one of a group of diseases requiringcoordinated healthcare delivery, and wherein each eligible populationpatient is eligible to enroll for coordinated healthcare delivery.